DEPARTMENT OF HEALTH SERVICES

Division of Care and Treatment Services
F-24277 (09/2016) /

STATE OF WISCONSIN

42 CFR483.420(a)(2)
DHS 134.31(3)(o)
DHS 94.03 & 94.09
§§ 51.61(1)(g) & (h)

1

INFORMED CONSENT FOR MEDICATION

Dosage and / or Side Effect information last revised on 10/04/2016
Completion of this form is voluntary. If not completed, the medication cannot be administered without a court order unless in an emergency.
This consent is maintained in the client’s record and is accessible to authorized users.
Name – Patient / Client (Last, First MI)
, / ID Number / Living Unit / Date of Birth
Name – Individual Preparing This Form / Name – Staff Contact / Name / Telephone Number – Institution
MEDICATION CATEGORY
/ MEDICATION /
RECOMMENDED
DAILY TOTAL DOSAGE RANGE /
ANTICIPATEDDOSAGE RANGE
Dementia/Alzheimer's treatment (mild to severe) (does not cure or stop the disease but can improve thinking ability) / Aricept
(donepezil) / 5mg - 23mg
The anticipated dosage range is to be individualized, may be above or below the recommended range but no medication will be administered without your informed and written consent.
Recommended daily total dosage range of manufacturer, as stated in Physician’s Desk Reference (PDR) or another standard reference.
This medication will be administeredOrallyInjectionOther – Specify:
1.Reason for Use of Psychotropic Medication and Benefits Expected(note if this is ‘Off-Label’ Use)Include DSM-5 diagnosis or the diagnostic “working hypothesis.”
2.Alternative mode(s) of treatment other than OR in addition to medications include
Note: Some of these would be applicable only in an inpatient environment.
Environment and/or staff changes / Rehabilitation treatments/therapy (OT, PT, AT)
Positive redirection and staff interaction / Treatment programs and approaches (habilitation)
Individual and/or group therapy / Use of behavior intervention techniques
Other Alternatives:
3.Probable consequences of NOT receiving the proposed medication are
Impairment of Work Activities
/
Family Relationships
/
Social Functioning
Possible increase in symptoms leading to potential
Use of seclusion or restraint
/
Limits on recreation and leisure activities
Limits on access to possessions
/
Intervention of law enforcement authorities

Limits on personal freedoms

/

Risk of harm to self or others

Limit participation in treatment and activities

Other Consequences:

Note: These consequences may vary depending upon whether or not the individual is in an inpatient setting. It is also possible that in unusual situations, little or no adverse consequences may occur if the medications are not administered.

See Page 2

F-24277 / Medication: Aricept - (donepezil)

4.Possible side effects, warnings, and cautions associated with this medication are listed below. This is not an all-inclusive list but is representative of items of potential clinical significance to you. For more information on this medication, you may consult further with your physician or refer to a standard text, such as the PDR. As part of monitoring some of these potential side effects, your physician may order laboratory or other tests. The treatment team will closely monitor individuals who are unable to readily communicate side effects in order to enhance care and treatment.

Continued – Possible side effects, warnings, and cautionsassociated with this medication.Most Common Side Effects: The most common side effects include: diarrhea, loss of appetite, nausea, vomitting, muscle cramps, insomnia and fatigue. Adverse effects may be more frequent at dose escalation and tend to resolve with continued use. Check with your doctor as soon as possible if you experience any of these adverse effects.
Less Common Side Effects: Check with your doctor as soon as possible if any of the following less common side effects occur: abnormal dreams; constipation; dizziness; drowsiness; fainting; frequent urination; headache; joint pain, stiffness, or swelling; mental depression; pain; unusual bleeding or bruising; weight loss.
Rare Side Effects: Check with your doctor as soon as possible if any of the following rare side effects occur: black, tarry stools; bloating; bloody or cloudy urine; blurred vision; burning, prickling, or tingling sensations; cataract; chills; clumsiness or unsteadiness; confusion; cough; decreased urination; difficult or painful urination; dryness of mouth; eye irritation; fever; flushing of skin; frequent urge to urinate; high or low blood pressure; hives; hot flashes; increased heart rate and breathing; increase in sexual desire or performance; increased sweating; increased urge to urinate during the night; irregular heartbeat; itching; loss of bladder control; loss of bowel control; mood or mental changes, including abnormal crying, aggression, agitation, delusions, irritability, nervousness, or restlessness; nasal congestion; pain in chest, upper stomach, or throat; problems with speech; runny nose; severe thirst; shortness of breath; sneezing; sore throat; sunken eyes; tightness in chest; tremor; troubled breathing; wheezing; wrinkled skin.
Caution: Before you have any kind of surgery, dental treatment, or emergency treatment, tell the medical doctor or dentist in charge that you are using this medicine. Taking donepezil together with certain medicines that are used during surgery or dental or emergency treatments may increase the effects of those medicines and cause unwanted effects.
See PDR for an all-inclusive list of side effects.
By my signature below, I GIVE consent for the named medication on Page 1 and anticipated dosage range. My signature also indicates that I understand the following:
  1. I can refuse to give consent or can withdraw my consent at any time with written notification to the institution director or designee. This will not affect my right to change my decision at a later date. If I withdraw consent after a medication is started, I realize that the medication may not be discontinued immediately. Rather, it will be tapered as rapidly as medically safe and then discontinued so as to prevent an adverse medical consequence, such as seizures, due to rapid medication withdrawal.
  2. Questions regarding this medication can be discussed with the Interdisciplinary Team, including the physician. The staff contact person can assist in making any necessary arrangements.
  3. Questions regarding any behavior support plan or behavior intervention plan, which correspond with the use of the medication, can be directed to the client’s social worker, case manager, or psychologist.
  4. I have the right to request a review at any time of my record, pursuant to § 51.30(4)(d) or § 51.30(5)(b).
  5. I have a legal right to file a complaint if I feel that client rights have been inappropriately restricted. The client’s social worker, case manager, or agency/facility client rights specialist may be contacted for assistance.
  6. My consent permits the dose to be changed within the anticipated dosage range without signing another consent.
  7. I understand the reasons for the use of the medication, its potential risks and benefits, other alternative treatment(s), and the probable consequences that may occur if the proposed medication is not given. I have been given adequate time to study the information and find the information to be specific, accurate, and complete.
  8. This medication consent is for a period effective immediately and not to exceed fifteen (15) months from the date of my signature. The need for and continued use of this medication will be reviewed at least quarterly by the Interdisciplinary Team. The goal, on behalf of the client, will be to arrive at and maintain the client at the minimum effective dose.

1

Client Initial / Date
SIGNATURES / DATE SIGNED
Client – If Presumed Competent to Consent/Parent of Minor/Guardian (POA-HC) / Relationship to Client Self
Parent Guardian (POA-HC)
Staff Present at Oral Discussion / Title
Client / Parent of Minor / Guardian (POA-HC) Comments
As parent/guardian (POA-HC) was not available for signature, he/she was verbally informed of the information in this consent.
Verbal Consent
Obtained by – PRINT – Staff Name / Date Obtained / Written Consent Received Yes No
Obtained from – PRINT – Parent/Guardian (POA-HC) Name / Date Expires / Date Received

1

Client Initial / Date